This was the most formidable surgical operation in my experience. But when the Surgeon-general called for reports of surgical operations of the war for the Medical and Surgical History of the Rebellion, while accepting others that I reported, this one he would not accept, or it was overlooked. Austin, Texas.

[From the American Practitioner and News, February 9, 1895.]

On The Physiological Action Of Antitoxin In Diphtheria By G. P. Hackenberg, M. D

That antitoxin has favorable effects in certain stages of diphtheria has been fully verified. To know in what manner it becomes curative is to use the remedy scientifically and with general success in a certain line of cases.

The question that presents itself is, What makes the difference between a mild case of diphtheria and that of a virulent form ? The difference is not owing so much to the primary cause of the disease, the diphtheria bacillus, as to the constitution of the patient. It is the condition of the constitution of the patient having the disease that demands the keenest attention, and, further, it should be fortified with prophylactic treatment in the earliest stage of the disease against grave symptoms, not waiting for their development with their consequent unfavorable prognosis.

Idiosyncrasy (a neglected subject of vital importance) may prove a prominent factor in giving character to a disease. There is even a constitutional predisposition to some form of disease which tends to regulate its intensity. This constitutional feature may make the disease exceedingly mild, or may induce its acceptance with such activity as to prove fatal in spite of any remedy that may be enforced. This election of a disease through idiosyncrasy is a remote influence as an etiological element. The immediate cause of the disease is the pathogenesis incidentally induced. The immediate causes of disease would be of uniform effect if there were no diversity of physical development in animal life.

Let us take a case of well-developed diphtheria in its first stage, before much of a toxicohemia is developed. The habitation of the bacilli is strictly local, confined to the mucous membrane. Their presence under a system of cellular radiation, co-operative with a venous circulation (vide Medical and Surgical Reporter, January 16,1894), contaminates the general system with its poison. The activity of the absorbents of the poison gives character to the disease, either making it mild or virulent. It is not the amount of poison always that causes the violence of the disease, but the time consumed in taking it into the system, ccsteris paribus. There are many clinical examples that illustrate this principle. A person may take a dangerous dose of strychnine on an empty stomach, when the absorbents are in the highest state of activity; the same dose after a full meal may produce little apparent effect, as the poison would be admitted into the system gradually. This shows the danger of being exposed to an infectious disease with an empty stomach. The same physiological law holds good in giving character to many diseases, as cholera, yellow fever, typhus fever, smallpox, and scarlatina. Therefore, in the initiatory stage of infectious diseases the starvation treatment is to be deprecated. However, to "feed a fever " is a practice in medicine requiring discrimination. The toleration of drugs is brought under this same physiological law; the degree of their absorption is the measure of their effects.

On what principle are diphtheritic pathogenics admitted into the system ? The function of the albuminoids renders a physiological protection against many harmful ingredients that may find their way into the system. But it appears the albuminoids fail to exercise a full protection against a poison of the body of its own production. In therapeutics we know that each medicine has its organ of election, and likewise its own peculiar method of assimilation and elimination. There is evidently a fixed systemic force that invites these pathological poisons into the circulation, where it clings as an incubus to some part of the body. It stimulates a peculiar sense, as the sense of thirst or hunger, for the purpose of effecting its elimination. What we eat and drink serves equally as much to carry off the waste of the body as to give growth and nourishment. Disease is an irritant, and excites a force for its own destruction, but unfortunately so desperate is often the systemic struggle with it that the patient may fail to stand the strain, and after all his physical energies are expended he dies. Here lies a common cause of death.

The antitoxin is erroneously considered by many to be an antidote to the diphtheric poison. It has systemic effects, but it never kills the bacilli. It appears to lessen the forces of the pathogenic poison on a repellant principle, or rather a change in the power of absorption. If the patient has sufficient vital force to bear the reaction he will recover. The remedy causes a histolytic suspension, leaving an elimination to dispose of the toxemia; but with this difference, as in vaccination, the antitoxin may leave a permanent immunity of the disease, showing that a metamorphosis of certain molecules in the cellular tissue took place. This metamorphosis may become pathological, and may remain dormant for years, finally becoming explosive and revealing itself in an active disease. Hydrophobia may be cited as an example. We confidently assign this attribute to the cellular tissue, as it is less subject to mutation than any other part of the body. They are the builders of all atomic structure and furnish the material for growth and traumatic reparation. The age of a cicatrix confirms these views. It is true the body may be subject to waste and emaciation, but the adipose material is a distinct element of the body. The cells may carry the fat, but may surrender it without impairing their condition to be again inhabited by the same material. There may be an exception to this in old age; therefore the wrinkles of the old.

It is important to know what tissue or fluid of the system takes up the diphtheric poison. The cellular tissue, the lymphatic and vascular circulation are all more or less contaminated with it. But they are not all affected in the same degree, nor of the same nature ! It is not in the cellular tissue what it is in the serum of the blood. It is subject to the same physiological changes in passing through the different organs or tissues as any other ingesta that may be admitted. . The first and most remarkable change of diphtheria is at the original seat of the disease. The bacilli are limited and strictly local, but the toxin they breed, admitted into the system, becomes a changeable compound with the different secretions of the body. If this were not the case the injection of the antitoxin into the cellular tissue would not prove prophylactic and curative. The injection admits the virus as it exists in the diphtheritic serum to frustrate the fount of poison by impairing or destroying the "sense" for its further admission. To use a military phrase, the cellular tissue is the breastworks of the nervous system, and so potential are these that many diseases, as measles, smallpox, yellow fever, etc., can never break through them the second time.

We propose to dispense with the animal diphtheric serum as a remedy for diphtheria, and in place use the serum direct from the diphtheric patient - even to inoculate the patient with his own serum. To inject the patient with his own serum is not likely to alter the efficiency of the treatment. The serum injected into the cellular tissue has not the same effect it had in the blood, having to do with a different histological element. A few drams of water may be injected into the circulation without any apparent effect, but inject the same quantity of water into the cellular tissue and almost immediate striking effects are produced.

It is a very simple operation to procure the human serum for this experimentation. Produce a cantharic blister about the size of a dollar on a diphtheric subject. With a sterilized hypodermic syringe draw a sufficient quantity of the serum out of the unbroken bleb in a manner not to admit atmospheric air into the instrument. Make the injection in the nape of the neck between the scapulae, or other favorable localities may do as well. The ultimate principle of the two serums' are about the same. The antitoxin from the animal serum is a toxin isolated from the ptomaines of the diphtheria bacilli, and used as a remedy after its mutation by means of the blood of an animal, and an intricate chemical manipulation. The human antitoxin is strictly a physiological product, administered with no therapeutic complication, and appears more reliable and is nearly always readily secured.

The topical treatment for diphtheria is of great importance, and almost any of the authenticated remedies specially recommended for diphtheria given in "Medical Consultation Book" are destructive to the bacilli, and do their part to favor a cure.

Austin, Texas.